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Clinical Crossroads
Clinician's Corner
March 2, 2011

Perinatal Care for Incarcerated Patients: A 25-Year-Old Woman Pregnant in Jail

Author Affiliations

Author Affiliations: Dr Clarke is Associate Professor of Medicine and Dr Adashi is Professor of Medical Science, Brown University, Providence, Rhode Island.

JAMA. 2011;305(9):923-929. doi:10.1001/jama.2011.125

More than 6 million men and 1 million women are under US correctional control, be it jail, prison, probation, or parole. On any given day, about 250 000 women and adolescent girls are behind bars, a number well in excess of those documented for all other sovereign nations. Moreover, women and girls represent the fastest-growing segment of the prison and jail populations. Approximately 75% of these women are mothers of minor children (leaving 200 000 children “motherless”) and as many as 10 000 may be pregnant. Primarily designed for male offenders, the US correctional system is struggling to meet the specialized needs of its female inmates. Although incarceration during pregnancy is both stressful and dehumanizing, most studies paradoxically document better outcomes for pregnancies managed behind bars than for women of similar socioeconomic status whose pregnancies are managed in the community. Using the case of Ms A as a springboard for discussion, the issues, benefits, and challenges of caring for an incarcerated pregnant woman are addressed, as is the importance of family planning services to those about to be released.

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2 Comments for this article
Readers Respond: Care at the Crossroads, Incarceration and Pregnancy
Carolyn B. Sufrin, MD, MA | University of California, San Francisco Obstetrics & Gynecology, Dept. of Public Health, Jail Health,
Pregnancy for incarcerated women represents a complex crossroads of care: medical standards, correctional regulation, gender discrimination, criminal and medical management of substance abuse, and the impact of these on birth outcomes. The 8th amendment guarantees the right to health care for incarcerated persons; nonetheless, the variable and often inadequate services have been well documented 1, 2. For many women, jail intake may be the first time they learn they are pregnant. This moment in pregnancy care highlights the challenges of "choice" in a setting where even mundane choices -- like when to wake up -- are limited. Incarcerated women have a constitutional right to obtain an abortion 2. However, one study found that while 68% of correctional health professionals said women can obtain an abortion, many fewer facilitate access 3.
When a woman chooses to continue a pregnancy, she should receive standard prenatal care, either on-site or via transport to a local hospital. Despite clear protocols from APHA 4 and NCCHC 5, an evaluation found that 38 states had inadequate prenatal services 1. The lack of standard prenatal care further challenges the management of common co-morbidities, like substance abuse. Acute opiate withdrawal during pregnancy increases the risk of miscarriage and stillbirth, and opiate-addicted women are transitioned to methadone or buprenorphine 6. This medical management requires immediate attention and prolonged waits in holding cells may put the pregnancy at risk.
Nowhere is the "crossroads" more apparent than in the practice of shackling in labor. Both ACOG and the NCCHC condemn this medically unsafe practice citing its danger when obstetric emergencies occur; the United Nations also declares it a human rights violation 7. From a security perspective, shackling is unnecessary; 65% of women are incarcerated for non-violent crimes 8. Additionally, labor pains and use of epidural anesthesia make fleeing unlikely. Nonetheless, only 10 states have anti-shackling laws.
Birth outcomes have been shown to be worse than in the general population, indicating that these are high risk pregnancies. However, when compared to disadvantaged controls, incarcerated women had lower rates of stillbirth and low birthweight 9. While the relative stability incarceration may improve immediate outcomes, few studies have reported the long term consequences on families. Most mothers become separated from their babies after delivery, as only 13 states have prison nursery programs. Postpartum separation is disruptive not only for the nuclear family, but also for extended families and communities which assume the responsibility of childcare 10.
Much needs to be done in this country to improve the care of incarcerated pregnant women. The report Mothers Behind Bars provides a comprehensive evaluation of pregnancy care in prisons, with concrete recommendations for change 1. As physicians, we should encourage our state legislatures to put an end to the unsafe and inhumane practice of shackling in labor. Currently, 12 states are hearing bills which pertain to this issue (Table 1). If the US is to improve care for incarcerated, pregnant women, it must see the complex social, economic, and political circumstances which underpin the need to improve pregnancy care.
Table 1 States with Active Anti-Shackling Bills in State Legislature
Arizona HB 2294 California AB 568 Connecticut GA 124 Florida SB 1086, HB 779 Hawai'i HB 131, SB 219 Idaho HB 163 Illinois HB 1958 Iowa SF 101, SF173 New York SB 375 New Jersey Assembly No 3492 Oregon SB 632 Rhode Island SB 165, HB5257
*Courtesy of ACLU Reproductive Freedom Project, February 18, 2011

ACOG: American College of Obstetricians and Gynecologists APHA: American Public Health Association NCCHC: National Commission on Correctional Health Care
The Rebecca Project for Human Rights. Mothers Behind Bars: A state-by-state report card and analysis of federal policies on conditions of confinement for pregnant and parenting women and the effect on their children. 2010 National Women's Law Center. Kenny,L. 2007 Women Don't Check Their Reproductive Rights at the Jailhouse Door Women, Girls and Criminal Justice. Feb/Mar 2007: 21-28. Sufrin CB, Creinin MD, and Chang JC. Incarcerated Women and Abortion Provision: A Survey of Correctional Health Professionals. Perspectives on Sexual and Reproductive Health 2009 Mar; 41(1): 6-11. Standards for Health Services in Correctional Institutions. American Public Health Association. Washington, DC; 2003:108. National Commission on Correctional Health Care. Women's Health Care in Correctional Settings (2005 Update). Journal of Correctional Health Care. 2005; 11:381-389. Jones HE, Kattenbach K, Heil SH, et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. 2010. N Engl J Med. 363: 2320-31. United Nations Human Rights Committee, Eighty-seventh session, July 2006, page 11. US Department of Justice: Bureau of Justice Statistics. Bulletin: Prisoners in 2009.http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=2232 (Accessed February 22, 2011) Knight M & Plugge E. The outcomes of pregnancy among imprisoned women: A systematic review. 2005; 112: 1467-1474. Golden, R. (2005). War on the Family: Mothers in Prison and the Families They Leave Behind. New York: Routledge. Conflict of Interest: None declared
A 25-year-old woman pregnant in jail
Pietro Ferrara, MD | A. Gemelli University Hospital, Rome
To the Editor: With regard to Dr Delbanco's discussion,(1) in particular what are the outcomes for the new mother, the child and nuclear family, as a paediatrician I think that the same sanitary assistance given to the population outside prison must be equally guaranteed to prisoners. Children are clearly a separate category, with needs more different from other prison populations. In our experience, the law allows female prisoners to keep their babies with them until the age of 3 years in specific "nest areas" inside female detention centres.(2) Parental contact is fundamental for the child and must be guaranteed inside the prison as a constitutional principle. There should be a balance between the possible damage of separating children from their mothers and the potential harm to children kept in prison. The choice to separate mothers and children is rarely justified; it often took place because of the inadequacy of the detention centre. Although there is poor direct evidence about the long-term effects of separating or keeping mothers with their babies while in prison, the role of the family as an essential element for mental and emotional development of the child is well known. From 0 to 3 years of age the interactive context of children coincides with the maternal figure and the mother's psyche becomes an integral part of the child's mind.(3,4) The mother and baby relationship can promote prisoners' rehabilitation to the community.(5) Children living in prison with their mother represent a vulnerable group with particular healthcare needs and the access to the prison health service may be the first opportunity for an inmate to receive medical care. Moreover, the period in prison could offer opportunities to improve the prisoner's health. We have verified that during their stay in prison the children's health was not damaged (relative to their growth, immunisation status and medical assistance) but on the contrary there was an improvement in their health.(2,6) To improve the condition of these mothers and their relationships with the babies, more attention should be paid to healthcare promotion by providing healthcare educational programmes, with periodic meetings on important themes such as breast-feeding, infant sleeping position, accident prevention, first steps, alcohol and drugs use. Prison may act as a gateway to facilitate the health and general well-being of these babies. A civil society is one that cares for its babies. Finally, I recommend for Ms A simply to be mum. Like all mothers of the world. Pietro Ferrara, MD
A. Gemelli University Hospital
1. Delbanco T. A 25-Year-Old Woman Pregnant in Jail. JAMA 2011
February 9;305,6.[Epub ahead of print]. 2. Ferrara P, Gatto A, Nicoletti A, Emmanuele V, Fasano A, Curro V. Health care of children living with their mother in prison compared with the general population. Scand J Public Health 2009 May;37(3):265-272.
3. Poehlmann J. Incarcerated mothers’ contact with children, perceived family relationships, and depressive symptoms. J Fam Psychol 2005;19:350-357.
4. Howard K, Martin A, Berlin LJ, Brooks-Gunn J. Early mother-child separation, parenting, and child well-being in Early Head Start families. Attach Hum Dev 2011 Jan;13(1):5-26.
5. Hotelling BA. Perinatal needs of pregnant, incarcerated women. J Perinat Educ 2008;17(2):37-44.
6. Byrne MW, Goshin LS, Joestl SS. Intergenerational transmission of attachment for infants raised in a prison nursery. Attach Hum Dev 2010 Jul;12(4):375-393.).
Conflict of Interest: None declared